1. MACDDS July 2012 The Change Wolf is at the Door! Les Wagner Executive Director October 9, 2012

2. MACDDS July 2012

3. EVOLUTION 1969 – parents in Pike County started the county board initiative. Until recently, DMH has administered case management and all Home and Community waivers. DMH historically has determined who is eligible for services, what their plan would be and what services they would receive.

4. County Boards in Missouri In 1969 Missouri passed legislation allowing counties with voter approval to establish a property tax levy Funding must be used to support individuals with developmental disabilities. 86 of 115 counties have passed local tax levies. Local tax levies in 2010 totaled over $82.5 million.

5. SB 40 Boards 1969

6. SB 40 Boards Today

7. County Boards in the beginning… In the 70s and 80s, most county boards used local resources to develop new services: –Sheltered Workshops –Group Homes –Other Related Services

8. Matching Fund Opportunities (What big eyes you have!) In the late 80s Division of DD started developing home and community Medicaid waivers. –County Boards started leveraging local funds in the DD waivers. –In 2005, County Boards matched over $5.8 million of local funding to purchase Medicaid waiver services valued in excess of $12 million. –Division projects County Boards in 2012 will match over $14 million of local funding to purchase DD Medicaid waiver services.

9. Crisis Only Era The Department of Mental Health allows services only to those in crisis. Consequence: County boards are unable to access Medicaid waiver services for individuals on their county wait lists. MACDDS conducted research to determine if a county-based Medicaid waiver could be used to allow counties with local funding to preventatively address needs of individuals.

10. MACDDS sought a Missouri Foundation for Health grant to support waiver research, bringing expertise in from national consultants. PfH was created as a result. Today, MACDDS continues to seek new and innovative opportunities to increase services.

11. PARTNERSHIP FOR HOPE

12. Partnership for Hope (The better to see with, my dear.) Fundamental systems change - prevention emphasis. The end of the crisis only era. No longer requires individuals to wait years before receiving services. Individuals and families receive support services sooner at a dramatically lower cost.

13. Partnership for Hope Positive outcomes: Individuals are able to stay in their own home. Parents are able to eliminate or delay need for more costly residential services. Individuals continue to live in their own community. Families stay connected.

14. Partnership for Hope PfH is expected to delay or prevent residential services cost for over a thousand individuals. PfH waiver services average $25 per day per person. Residential services are projected to cost over $200 per day per person. Delaying more costly residential services for 100 individuals for a year saves $6.3 million a year.

15. Partnership for Hope County boards determine who participates and the services to be planned and provided. Want to guess what happened next?

16. DD System Redesign Utilization Review Scores Medicaid Eligible Individuals 12 Served with New State Resources in the DD Waivers 11 10 987654321987654321 Proposed Solution Individuals receive services using County Based Waiver if local resources were available.

17. Partnership for Hope Waiver

18. Number of New Individuals Served Each Year

19. Budget – Economic Impact Division of Developmental Disabilities – Partnership for Hope Maximum Projected Expenditure for 1,270 Individuals for Fiscal Year 2012 Total Revenue $15,240,000

20. Partnership for Hope Waiver Original Counties Participating – October 1, 2010

21. Partnership for Hope Waiver Counties Added in February 2011

22. Partnership for Hope Waiver Counties Added in September 2011

23. Partnership for Hope Waiver Counties Added in February 1, 2012

24. Partnership for Hope Waiver Counties Added in August, 2012

25. Partnership for Hope Are you all ears yet?

26. Partnership for Hope Employment Services 1.Job Discovery –Includes: Volunteerism Job exploration Job shadowing Employment preparation (resume development, work procedures) Business plan development for self-employment 2.Job Preparation –Training and work experience to teach the skills necessary to succeed in paid community employment Volunteerism Following directions Focusing on tasks Completing tasks Appropriate work place attire Hygiene 3.Community Employment –Competitive work in an integrated work setting. 4.Co-Worker Job Supports –Employer provides job supports as a part of the natural workplace

27. Partnership for Hope Other Support Services Day Service Personal Assistant Temporary Residential Dental Services Assistive Technology Behavior Analysis Positive Behavior Supports Community Specialist Environmental Accessibility Adaptations Occupational Therapy Physical Therapy Speech Therapy Transportation Professional Assessment and Monitoring Support Broker (available to those who self or family direct their supports)

28. COUNTY-BASED TARGETED CASE MANAGEMENT

29. Budget State Case Manager s Local Case Managers Total Case Management FTEs FY 2006502.17107.53609.70 FY 2012285.89382.35668.24

30. Case Management In 2006 – 17 Counties providing local TCM services supporting 4,301 individual, 15% of persons served Currently – 84 counties providing local TCM services supporting over 15,294 individuals, 49% of persons served

31. Counties with Local Targeted Case Management Services As of July 2006

32. Counties with Local Targeted Case Management Services

33. County Boards in Missouri 2011

34. Growth Dramatic increases in persons served Enrollment in waivers Partnership for Hope expansion Targeted Case Management Employment initiatives Legislative initiatives Membership growth

35. MACDDS Growth 2001 to 2011

36. MACDDS VISION: To be an effective catalyst – shaping public policy and practice for people with developmental disabilities. MISSION: Dedicated to promotion of county initiatives in developmental disability services.

37. Member Benefits Identification of Priority Issues/Problems Development of Solutions Monitoring and Evaluation of Trends Reduced Waiting Lists Improved Training and Compliance Legal and Technical Assistance for SB 40 boards Confidential Member Networking Identify and Share Best Practices Assistance Locating Additional Resources

38. Additional Member Benefits for Related Private Organizations Access to decision makers Opportunity to participate in MACDDS committees and networking including: –Targeted Case Management –Residential Provider –HR and related RPO Membership dues are $1500/year

39. Issues Systems Problems – organization changing too fast to manage change Need for Consistent Liaison with State Government Accountability and Sustainability Major reforms – Federal and State i.e., Balancing Incentives Program, Affordable Care Act

40. Issues (What big teeth you have…) –Revisions to TCM contracts –Match agreements –Eligibility and referrals disputes –MMAC compliance audits –Waiver amendments –Waiver definitions –Issue du jour

41. 2013 Legislative Priorities Expand County and State Partnerships –Support the state in fully funding match for Medicaid Waivers. –Expand the Partnership for Hope to assist individuals in becoming self-sufficient productive citizens. –Explore other county initiatives directed at efficiencies. –Oppose actions undermining county boards’ statutory authority or that would impact revenue or appropriations affecting individuals with developmental disabilities.

42. 2013 Legislative Priorities Essential Health and Safety –Stabilize community supports for Missouri’s most vulnerable citizens through sufficient funding of long term quality providers. –Continue to reduce the census of Habilitation Centers. Redirect Habilitation Center funds to allow individuals to explore community living and become productive citizens. –Provide statewide specialized community supports for individuals in medical or behavioral crisis. –Expand employment opportunities for people with developmental disabilities by incentivizing businesses who employ them at or above minimum wage. –Maintain Missouri Department of Transportation funds and support state and local transportation initiatives to allow people to access their communities for medical and employment purposes.

44. Special thanks to the Division of Developmental Disabilities for their assistance in providing graphics and information provided in this presentation. Les Wagner, Executive Director MACDDS 29 S. 9 th Street, Suite 208 Columbia, MO 65201 573-442-5599 leswagner@macdds.org